--i(],-:~uij!!!j£.--=ilrp-=----------- · 2011-05-14 · in addition, two case studies (nasa and...

United States Marine CorpsCommand and Staff College

Marine Corps University2076 South Street

Marine Corps Combat Development CommandQuantico, Virginia 22134-5068

MASTER OF MILITARY STUDIES

Naval Aviation Culture Workshops

SUBMITTED IN PARTIAL FULFILLMENTOF THE REQUIREMENT FOR THE DEGREE OF

MASTER OF MILITARY STUDIES

Major Robert V. Rubio, USMC

Conference Group 9

AY 2007-2008

MentorandOralDefenseCo ~ ·tteeMember:~~Approved: ? .~ C/ ~Date :--'-~CLf-r.~~- ) !lOral Defens'e Committee Member: --I(],......-:~UIJ!!!J£.--=iLrp-=-----------Approved:_~\f~~~____________ ~Date: (6 {JI/'r-tL 0 ()

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Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18

Executive Summary

Title: Naval Aviation Culture Workshops

Author: Major Robert Rubio, USMC, CG#9, CSC

Thesis: Culture Workshops are beneficial in preventing and/or reducing aviation mishaps andthey are worth the invested time and money.

Discussion: Organizational culture impacts a unit's performance- for better or for worse.This research defines organizational culture and describes the dynamic relationships betweenindividuals, groups, and leaders. In addition, two case studies (NASA and US Airways) providesupplementary analysis to support the research. By understanding the context of organizationalculture through theoretical analysis, one will gain the perspective that organizational culture isrelevant in the military services-specifically in the naval aviation community.

Naval aviation is inherently a risky occupation. Each fiscal year, aviation mishaps cause loss oflife, material, and investment. A strong organizational culture in aviation is necessary to preventunnecessary mishaps. As a result, Naval Aviation Culture Workshops (CWs) were established tohelp commanders identify organizational issues and hazards that may cause aviation mishaps.CWs also identify command strengths and "best practices."

The Naval Safety Center (NSC) provided raw information that consisted of 288 naval aviationunits over a seven year period (FY 2001-2008). Additionally, the raw data included completionof CW's and Class "A" Flight Mishaps (FMs). This research will validate the effectiveness ofthe Navy's CW by determining if there is a correlation between the execution of a CW and thelikelihood of a mishap.

Conclusion: The CW Program is effective in reducing and preventing Class "A" PM whenconducted every two years for non-deploying units and when made mandatory for units that aredeploying. The Marine Corps should consider instituting requirements such as the Navy's,instead of the CW being an optional requirement. The Department of the Navy should providenecessary manpower and fiscal requirements to bolster Naval Safety Center (NSC) and MarineCorps efforts to provide CW's to aviation and ground units.

i

C'

1

DISCLAIMER

THE OPINIONS AND CONCLUSIONS EXPRESSED HEREIN ARE THOSE OF THEINDIVIDUAL STUDENT AUTHOR AND DO NOT NECESSARILY REPRESENT THE

VIEWS OF EITHER THE MARINE CORPS COMMAND AND STAFF COLLEGE OR ANYOTHER GOVERNMENT AGENCY. REFERENCES TO THIS STUDY SHOULD INCLUDE

THE FOREGOING STATEMENT.

QUOTATION FROM, ABSTRACTION FROM, OR REPRODUCTION OF ALL OR ANYPART OF THIS DOCUMENT IS PERMITTED PROVIDED PROPER

ACKNOWLEDGEMENT IS MADE.

11

Figure 1.Figure 2.Figure 3.Figure 4.

Table 1.Table 2.Table 3.Table 4.Table 5.Table 6.Table 7.

Illustrations

Page

Naval Aviation Mishap History........... 14Naval Aviation 1 Oct 00 to 28 Nov 07 22Which Column Would You Rather Be In.. 23GWOT Mishaps v. Class "A" FMs 24

Tables

Page

Naval Aviation (Navy and Marine Units) :..... 22Navy Rotary-Wing Units........ .. . .. . .. .. . 34Navy Fixed-Wing Units 34USMC Rotary-Wing Units 34USMC Fixed-Wing Units . . . . . . . .. . .. . .. .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. 34Navy Fixed/Rotary-Wing Units.... . . . . .. .. . .. . .. . 34USMC Fixed/Rotary-Wing Units 34

111

Table ofContents

Page

Executive Summary '" 1

Disclaimer. . . . . .. . .. . . . . .. . .. . . . . . . . . . . . . . .. . . . . . .. .. . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . .. . . . . .. 11

List of Illustrations ..... .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .... 111

Preface '" '" '" VI

CH. 1 INTRODUCTION............................................................................. 1Prologue '" 1Statement of the Problem.......................................................................... 1Rationale .. . . . . . . . .. . . . . . . . . . . .. . .. . .. . . . . . . . . . . .. . . . . . 2Assumptions .. . .. . . .. . .. . .. . . . . .. . .. . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . .. 2Objectives of the Research........................................................................ 2Significance of the Research. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . .. . . . . . . . . . . . . . .. . .. . .. 3Limitations .. . . . . . . . . . .. . . . . .. . .. . .. . .. . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . 3Delilnitations ' 4

CH. 2 WHAT IS CULTURE? '" '" . .. . . 5Culture and Climate .. . . .. . . . . .. . . . . . . . . . . .. . . . . . . . . . . .. . . . . .. . 6Culture and Leadership 7Followers and Leaders '" '" . .. . . .. . .. . 8

I

Non-Military Case Studies........................................................................ 9Military Culture..................................................................................... 12

CH. 3 NAVAL AVIATION 13Naval Aviation Safety Program.................................................................. 13Operational Risk Management (ORM) 15

CH.4 ORIGINS OF THE CULTURE WORKSHOP (CW) PROGRAM................ 17CW Requirements. . .. . . . . . . . . . . . .. . .. . . . . .. . . . . . . . . . . . . . .. . .. . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . 17Purpose 18Mission Statelnent .. . . . . . . . . . . . . . .. . .. . .. . .. . .. . . . . .. . . . . . . . .. . .. . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . .. 19Three Pillars of the CW 19CW Trends Analysis '.' . . . . . .. . . . . .. . . . . .. . . . . .. . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . .. . . 21CW Expansion , '" 25

CR. 5 CONCLUSION........................................................... 26Recommendations '" " , " . . .. . .. . . 27

IV

~1I

ITable ofContents (Cont'd)

Page

Endnotes 28

Glossary. . . . . . . . . . . . . . . .. . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . .. . .. . . . . . . . .. . . . . .. 31

Bibliography .. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . .. . . . . .. . .. . .. . .. . . . . . . . . . . . . . . . . .. 32

Appendix " ;.. .. . .. .. . . . . .. . . .. .. .. .. .. .. . . . .. . .. . .. . .. 34A. Navy and Marine CW Tables

v

I-II

Preface

During my three years as the Rotary-Wing Aviation Safet¥- Officer at Headquarters,

United States Marine Corps, I observed that military policy makers relied on mishap metrics to

gauge the Corps' success in reducing aviation mishaps. That is, at the end of each fiscal year,

the number of mishaps is calculated into mishap rates that are then compared against other

services to identify if the Corps is doing better than any ofthe other armed services. The less

mishaps the Marine COlPS had during the fiscal year- the better. The Department of the Navy

invests large sums ofmoney in teclmology to upgrade or build new aircraft systems in order to

fix mechanical problems or aid to prevent pilot error. However, I believe investing in

technological upgrades is a good short-term solution to reduce or prevent mishaps but theIi\

dysfunctional cultures that lead to mishaps need to also be reviewed and improved..,:.'" .1

Culture workshops identify the "why" ofhow mishaps occur in an organization. The

workshops also identify best command practices within an organization. The NSC's Culture

Workshop Program is more than a decade old and is expanding outside of the aviation

community to include sub-surface units, "blue water" Navy units, and Marine Corps ground

coinbat elements. The CW program expansion is a positive testament that unit commanders are

proactively identifying human factors that can improve operational excellence.

I would like to thank the NSC for providing statistical infonnation to aid in my research

and Commander Jolm Morrison, Program Manager of the Culture Workshop Program, for his

sound and helpful advice. It is also noteworthy to aclmowledge all ofthe Navy and Marine

Corps Culture Workshop Facilitators who spend tremendous amolmts of effort and personal time

to help commanders strive for a better and healthier organizational culture that can lead to

success.

VI

CHAPTER 1

INTRODUCTION

Prologue

Organizational culture is a compilation of values and accepted norms that is shared

among the members of an organization. 1 Organizational culture is viewed as either negative or

positive- contributing to the failure or success of an organization. The symbiotic relationship

between members and leaders of an organization is thus important to realize that nurturing

culture to meet mission accomplishment is critical to th~ survival of an organization.

The interaction of members and groups within an organization and their shared outcomes

and performance are attributable to leadership. Simply put, an organization's culture is a partial

reflection of the leader's personality.2 This dynamic human relationship between groups and

leaders form the human elements that contribute to the culture of an organization. Specifically,

human factors are actions or inactions by an individual or group that affect the performance of an

organization.

Statement of the Problem

A dysfunctional organizational culture creates a negative environment for

accidents to occur. Specifically, the human factors (actions or inactions by followers and

leadership of an organization) that create the culture greatly impacts organizational perfonnance.

Statistics from the Naval Safety Center (NSC) show that human factors account for 75% to 80%

of all mishaps and incidents; and they continue to be a major contributing factor in aviation

mishaps from year to year.3 To meet this challenge, the Naval Aviation Safety Program was

designed to protect personnel and assets by detecting, identifying, and implementing control

measures to eliminate hazards in the naval aviation community.4 A safety program like the

1

Culture Workshop (CW) is beneficial in preventing and/or reducing aviation mishaps and they

are worth the invested time and money. Furthermore, CW's can lead to an increase in

operational excellence while reducing or preventing fatal accidents.

Rationale

Aviation mishaps cost lives and material, thereby degrading an organization's mission

readiness and capability. CW's provide the lmit commander an unbiased assessment ofhis

organization without retribution from higher headquarters. CW's allow the unit commander to

identify and fix a problem before it impacts mission readiness. Identifying ~ysfunctional

organizational culture through the use of a CW can reduce mishaps and prevent its occurrence.

Assumptions

The Navy and Marine aviationlmits researched are assumed to have completed a'

Command Safety Assessment (CSA) and Maintenance Climate Assessment Survey (MCAS)

prior to conducting a CWo It is encouraged by the NSC for units to complete a CSA and MCAS

in conjunction with a CW to "triangulate" the identification ofnegative cultural trends. Utilizing

multiple tools by the unit commander provides additional measures Of organizational

effectiveness. The CSA and MCAS measure organizational safety climate in real time and

provides Commanding Officers with the tools to make corrections.5

Objectives of the Research

First, this research defines the tenn "culture" and its relationship with organizational

climate, leadership, and members. Second, by stating the elemental assumptions of

organizational cultural relationships and providing background case studies for theoretical

analysis, the impact of the CW's can be realistically determined. Third, military culture and

naval aviation will be discussed to bring the research into perspective. Lastly, the research will

2

examine the CW program in an attempt to identify whether CW's prevented and/or reduced the

occurrence of Class "A" Flight Mishaps (FMs). Additional information on the expansion of the

CW program to other occupational specialties and organizations will be mentioned.

For the purpose ofthis paper, the tenus "organization" and "unit" are interchangeable.

The context of the tenn "culture" will be to groups or members within an organization and not to

ethnic or religious groups. Culture, in this respect, refers to shared outcomes that contribute to

organizational effectiveness.

Significance of the Research

Navy and Marine Corps leadership tend to rely solely on metrics or benchmarks to

identify success or failure of a program. This study provides statistical analysis on the

effectiveness of the CW Program. The study also focuses on the human elements that fornl an

organization's culture and how action or inaction by its members can contribute to mission

success or errors that lead to mishaps. By understanding the dynamics of how individuals and

groups affect the perfonnance of an organization, this study provides leaders an alternative

approach to assess organizational culture and how it impacts mission intent and strategic goals.

Assessing organizational culture must be continuous to meet operational excellence.

Limitations

The NSC provided raw data for this research from October 1, 2000 (FY 2001) thru

November 28,2007 (two months into FY 2008). Theraw infonnation consisted of active duty

and reserve Navy and Marine aviation units, both fixed-wing and rotary-wing, that either

completed a CW or did not during the seven-year period. The raw data also included dates that

Class "A" FMs occurred.

3

Delimitations

As described in the glossary, there are three mishap categOlies determined by severity.

This research is delimited to correlating Class "A" FMs to units that either conducted a CW or

did not. A Class "A" FM is the most severe classification that may include a combination of the

following: damage greater than $1,000,000, loss of aircraft, loss oflife, and/or pennanent total

disability. Admittedly, by limiting the study to Class "A" FMs, the author stipulates CW

programs may also have an impact in reducing Class "B" and "C" mishaps. Based on the

experience ofthe author, Class "A" FMs typically receive greater attention and "media"

coverage by leadership and policy makers.

4

CHAPTER 2

WHAT IS CULTURE?

Upgrading and revising hardware systems are short ternl solutions to increase mission

capabilities and to prevent mishaps fi.-om occurring; however improving organizational culture

should be considered as a long term solution to root out dysfunctional cultures in an

organization.

Culture is a set of beliefs, norms, or shared values among a group or within an

organization that is accepted and often stable. Culture identifies and defines what an

organization is. It is normative, deeply entrenched, and difficult to change. Culture is passed

from generation to generation and sustained by indoctririating new members to share the

organization's culture. In his classic work, Organizational Culture and Leadership, Edgar

Schein defines culture as the following:

A pattern of shared basic assumptions that was learned by a groupas it solved its problems of external adaptation and internal integration,that has worked well enough to be considered valid and, there, to betaught to new members as the correct way to perceive, think, and feelin relation to those problems.6

From Schein's definition, one can understand that culture is shaped by group interaction,

developed over time, and influenced by leadership. Culture is embedded within an

organization's rules and policies and affects how tasks are executed and completed. The culture

of an organization reflects its history and the way it behaves, thus individuals playa vital role in

the organization's formation and growth.? Culture exists because individuals within an

organization accept and share the same values and beliefs.

The primary variable within an organization's culture is the human element. The human

element is dynamic in nature because it is greatly affected when there are multiple interactions

5

among people's beliefs and values. Over time, individual interaction among groups create and

accept shared values that lead to normalcy and stability of the organization. The human element

always creates and influences the culture of a unit and ultimately affects how the organization

operates, making culture difficult to change.

Culture and Climate

To some culture and organizational scholars, the terms "culture" and "climate" can be

confusing and the meanings interchangeable.8 However, both culture and climate are distinct. If

culture is the normative and accepted values of an organization, climate is the outwardly

expression ofthat organization's culture. As an outsider, climate is what you see, hear, smell,

and perceive. Contributing editors to The Handbook ofOrganizational Culture and Climate ..~~~:.

define climate as, "The feeling that is conveyed in a group by the physical layout in whiciF ,.

members of the organization interact with each other, with customers, or other outsiders ... ,,9

The climate of an organization is temporary, indicating a unit's perception at a point in

time. To an outsider, organizational climate is a snapshot or initial perceptions of a unit. In

contrast, culture is enduring and deeply entrenched in an organization. Nevertheless, culttire and

climate are very much related to each other. Culture (cause) lays the foundation to create the

~. climate (effect). For instance, a successful culture may enable or exhibit a climate that is

perceived by outsiders that groups within an organization are either happy with their workspace,

their mission, or with their leadership. On the other hand, a dysfimctional culture creates a

climate in which outsiders perceive one of discontent or one that creates complacency or lack of

integrity among the groups of that organization.

Although the climate of an organization indicates how it functions, assessing an

organization's climate can be misleading. As Schein elaborates, "If one perceives an

6

organization that looks informal and loose, it can be assumed that informality means playing

around and not working. Alternatively, if one sees a formal organization, one may interpret that

to be rigid and bureaucratic."lo Culture and climate are characteristics of an organization but it is

inevitably culture that lays the foundation for an organization's success or failure.

Culture and Leadership

Leadership, at all levels within an organization, contributes an important part of a unit's

culture. II Leadership has the power to create, maintain, and destroy organizational culture.

Although culture defines an organization and is influenced by its members, leadership is

ultimately accountable for the actions or inactions ofpeople within its charge. Leadership can

either accept the unit's culture or foster a change for the betterment of the organization. 12

There are different leadership styles; Leaders can either instill fear or inspire their

subordinates to complete missions. Leaders can also micromanage or enable people to

accomplish their tasks in a decentralized fashion. Regardless of the leadership style, leaders

have the responsibility of accomplishing missions and providing welfare for their subordinates. 13

It is leadership that actively sets the example for an effective organization.

Culture and leadership share a symbiotic relationship. Although they are intertwined,

leaders influence others to think, act, and follow orders. Influential leaders shape an

organization's culture by getting "buy-in" from subordinates to suit an overall vision or goal.

Within the military, commanders provide and issue a command philosophy to their unit. The

command philosophy is the commanding officer's cultural vision of his beliefs, values, and

principles to accomplish the unit's mission and to be understood and acted upon by his,

subordinates. Schein expresses that, "The leader must have certain insights, clear vision, and the

skills to articulate, communicate, and implemelit the vision... ,,14 Embedding this philosophy in

7

the organization ensures that the appropriate culture is in place to accomplish the commander's

mISSIOn.

Leaders not only create and maintain the organization's culture; they are also a driving

force for change management. Leaders may change the culture in an organization in response to

a change in the operational mission or because the unit's culture becomes dysfunctional to the

point a problem has broken out or a mishap has occurred. In his book, Schein shows that

leadership and culture are conceptually intertwined. IS He asserts that leadership can alter and

manage an organization's culture and states the following:

.. .it can be argued that the only thing ofreal importance thatleaders do is to create and manage culture; that the unique talentof leaders is their ability to understand and work with culture; andthat it is an ultimate act of leadership to destroy culture when it isviewed as dysfunctional. 16

Followers and Leaders

A leader without followers is an individual without an organization. Groups create

cultures while leadership provides the influence to maintain the current norms and the skill to

create the enviromnent for change. Therefore, the strength of an organization's culture is based

on the collective interaction of its members and the length and intensity of shared experiences in

the organization. 17

Before following any leader, groups first form a relationship based on a collective

identity.18 Regardless of whether it is a civilian or military organization, collective identity is

based upon beliefs, values, and nonns. These shared experiences become mutually reinforcing

thus creating a culture that is systemic and most often difficult to change.

Individuals within groups that espouse strong beliefs and values often become leaders.

These individuals are strong-minded, endorsed by the group, and act as the "voice" for the group.

8

A leader that has a vision for the group and is accepted by it creates the nucleus for culture to

form and enables the collective identity of the organization to perform.

An organization may consist of different types of followers. In the December 2007 issue

ofthe Harvard Business Review, Barbara Kellerman divides followers into five distinct sets:

1. Isolates who are detached2. Bystanders who observe but do not participate3. Participants who engage in some way4. Activists who feel strongly5. Diehards who are prepared to go down for a cause

As described, Isolates and Bystanders are bad followers and not conducive to an organization. 19

Participants, Activists, and Diehards represent favorable followers for an organization but

leaders must keep in mind that these followers may act upon their own interests and/or try to

change the organization's culture. It is not only important for leaders to have the "right stuff'

but to have the managerial ability to identify the effectiveness of the individual-group nonns that-

contribute to organizational culture.

Non-Military Case Studies

The following case studies represent two non-military vignettes in which culture affected

the performance outcomes of the organization. The National Aeronautical Space Agency

(NASA) case study typifies a dysfunctional institution that had a culture of complacency and

incompetence.2o The US Airways case study shows how a significant event forced a culture

change for the airline's survival.21 The outlying purpose of these two examples is to reinforce

that leadership is ultimately responsible for identifying negative trends that have taken root in an

organization's culture. The case studies serve to show how leaders should take the initiative to

create a new successful culture after a mistake or mishap occurs.

9

1. NASA

Established in 1958, NASA's space exploration program, backed with massive funding

and support, was successful against the Soviet Union in putting a man on the moon,z2 The

fonning culture within NASA developed into a "can-do" attitude. Senior NASA officials, as

well as the public, believed that spaceflight was safe and almost routine.23 Due to political,

public, and management pressure to build and launch more space shuttles, NASA's cultural

mindset changed fi:om "launch ifproven safe" to "launch unless proven unsafe. ,,24

NASA's culture was detrimentalto the safety ofthe program because it put mission first

over safety engineering concerns. NASA's dysfunctional culture resulted in two of the greatest\

catastrophic mishaps the public has ever seen. The 1986 Space Shuttle Challenger disaster was

the result of a defective O-ring that connected to the solid rocket motor joint. The commission

investigating the mishap discovered that the shuttle's O-ring limitations were ignored despite

senior NASA official's stance of "the mission is a GO." The investigation report also revealed

that the mishap was due to managerial and cultural mistakes.25 Eventually, the commission

.tasked NASA to implement their recommendations regarding technical and procedural changes,

changes to their management culture, and establishing a powerful safety office. Unfortunately,

due to a systemic mindset of "lalillch first and ask questions later" and the lack of asserting the

commission's reconunendations, NASA's entrenched culture resulted in another shuttle mishap.

The second catastrophic mishap for NASA was the 2003 Columbia disaster, which was a

result of heat tiles contacting the shuttle's fuselage. NASA engineers knew heat tile separation

was a reculTing probl~m for 10 years,z6 Senior management disregarded the engineers' concerns

and stated that it was routine for the tiles to fall off and that the risks were acceptable. The

"launch unless proven unsafe" attitude and culture was deeply entrenched at the leadership level.

10

JNavy Rear Admiral Steve Turcotte, former Commanding Officer of the NSC, was a member of

the Columbia Mishap Investigation Review Board and provided some insights as to the causal

factor ofthe mishap.27 Rear Admiral Turcotte deliberated that the mishap was due to a culture

that was dysfunctional in regards to the communication and relationship between the engineers

and senior management. He also identified that problems fixed by NASA were never followed

up periodically. The "fix and forget" mentality and the "We've been doing it like this for years"

cultural mindset enabled the Columbia mishap to occur.28

2. US Airways

In comparison to NASA's failure to initiate a culture change after a catastrophe, the US

Airways case study demonstrates how strong leaders enforce change within an organization with

new cultural concepts. The US Airways case study is a prime example of leadership altering an

organization's culture to ensure operational success.

In 1994, US Airways suffered two fatal crashes that resulted in fatalities. 29 Following

investigation and lack of public confidence, the airline's safety record came into question. US

Ailways senior leadership established a new position of "Vice President, Corporate Safety and

Compliance" in order to stop the declining culture which was affecting the company's bottom

line. The new position provided a new cultural mindset upon US Airways members that

emphasized safety and customer service and implemented a review on aircraft procedures and

standardization. After experiencing several mistakes and mishaps, US Airways survived because

its leaders influenced the right culture when change was needed.

11

Military Culture

The military's organizational culture is unique when compared to that of civilian

organizations. The military's rich and historical culture is rooted upon tradition and impresses

its espoused values and principles among its service members at the start of their careers. The

military's organizational culture is also rigid, structured, and conformity-based. During the first

phase of a service member's indoctrination, recruits are stripped oftheir identity and rebuilt to

conform to the values ofthe military culture. Although the military is an "all volunteer" force, it

selects individuals that will be culturally right for it. The wearing of a military uniform signifies

both organizational uniqueness and stratification within the organization.3o The military's

hierarchical and authoritarian nature demands discipline and control. Orders are executed by its

members via a chain of command that directs infonuation or orders from the top to the bdttom of

the "totem pole." The military's culture developed over time and is widely accepted by its

members and by the nation it protects. This unique military culture, unlike civilian

organizations, is designed to defend the Constitution of the United States.

The military's institutional and hierarchical process of executing missions has served

well over time but it is changing in the way it conducts "business" towards a more corporate-like

approach.3! Faced with a constrained budget and lack of resources to accomplish its mission, the

military is forced to do more with less. The military changed its organizational culture from a

rigid and "coercive" structure, to one of team-based values that are centered on the commander's

intent. A team-based culture that decentralizes tasks enables freedom of action or thinking to

complete the mission.

12

CHAPTER 3

NAVAL AVIATION

The previous chapter provided basic assumptions on culture and the dynamic human

relationships of an organization that creates and maintains it. This chapter will focus on military

culture, specifically the demanding and risky environment of naval aviation, to bring into

perspective the importance of organizational culture.

Naval aviation is a dangerous occupation. Squadron pilots, aircrew, and maintenance

perso1l1lel are constantly exposed to noise and movement of the aircraft in the environment they

operate, regardless ofpeace or wartime conditions. From conducting night landing traps on a

carrier to operating in the deserts of the Middle East, flying naval aircraft requires skill by pilots

and repair knowledge by maintenance persomlel. The demands ofnaval aviation require the

utmost vigilance by its members to ensuring the force preservation ofpersonnel and aircraft.

Naval Aviation Safety Program

Naval Aviation has come a long way from the culture of mass-producing aircraft to meet

wartime requirements during World War II, to present day operations. Historically, loss of life

and destruction of aircraft was a normal part of being in a dangerous profession. Today the

importance is in force preservation to meet the nation's needs. Accordingly, to meet the.

challenge of a resource-restricted environment, naval aviation changed its culture and how it

conducted business. Figure 1 depicts a positive trend towards efficiency and organizational

effectiveness as the result of improved aircraft tec1mology and instituting safety programs,

policies, and procedures. However, the trend has leveled out since the 1990's and into·the 21st

century.

13

706560

/Angleddecks

// --/~Aviation Safety Center.4 .."""

...~ .,Naval AvIation Maintenance Program

£-'(NAMP),1959 .

. /" RAG concept initiated

// /NATOPS Program, 1961

://" /// /squadron Safety program

"'-'/ ACT

'" / ORM

~~~~~~IN ~ ~ • ~ M

o5055

60

60

40

Naval Aviation Mishap Hist01Jl.USN/USMC, FY50-05

776 aircraftdeslroyedin

1954

-+--- Weapon system employment. training and tactics

Figure 1.·t-' ;

The Naval Aviation Mishap History graph was produced by the NSC, NAS Norfolk, VA.*The historical graph shows how aviation programs reduced the amount ofllaval aviation mishaps from 1950 to the

present day of submitting this research paper.

On October 9,2007, the Department of the Navy (DON) released a memorandum

conceming the Navy's obj ectives for Fiscal Year (FY) 2008 and beyond. The purpose of the

DON objectives was to identify critical issues that affect Navy and Marine Corps capabilities and

to provide areas of focus in order to improve work effectiveness and force preservation. One of

the objectives stated that the Navy-Marine Corps Team must, "Integrate Safety and Risk

Management into all on and off-duty evolution to maximize mission readiness and to establish

DON as an organization with world class safety where no mishap is accepted as the cost of doing

business.,,32 The DON's safety objective required a paradigm shift ofthinking from an historical

and traditional organization that accepts mishaps, to an organization that mitigates risks and

prevents mishaps. The DON objective reinforced the importance of a culture that is

14

jI

organizationally effective and one that preserves personnel and material, while operating in a

demanding and fiscally constrained environment.

Naval aviation's comerstone to success is its safety program. The Naval Aviation Safety

Program enhances operational readiness when it preserves the lives and enhances the well-being

of its members by protecting the equipment and material they need to accomplish the mission.33

)

The integrity of the safety program is the responsibility of the unit commander. The

commanding officer is charged to promote the safety program's policies and procedures set forth

in the unit to create an environment and culture that meets mission readiness by mitigating risks

and hazards.

.The goal of the Naval Aviation Safety Program is to eliminate or control potential causes

of damage and injury under human control. 34 Program elements such as the Command Safety

Assessment (CSA) and the Maintenance Climate Assessment Survey (MCAS) are utilized in

conjunction with a culture workshop. Both CSA and MCAS provide commanding officers the

tools to identify organizational trends that may lead to a mishap. 35 Prior to conducting a culture

workshop, commanding officers are provided the opportunity to execute the CSA and MCAS in

order to obtain quick feedback on their unit's strengths and weaknesses.

Operational Risk Management CORM)

ORM is integral to creating a safe and effective environment. ORM is a decision-making

process that is applied by leadership during the plamling process and executed by subordinates

during on and off-duty hours. The Navy and the Marine Corps apply the ORM process to all

activities whether it is a low or high-risk event. Applied successfully, ORM.preserves forces and

assets while accomplishing the mission. The ORM process is not about preventing or

eliminating "all" risks within the military.36 The military profession is inherently dangerous. As

15

delineated in the Naval Aviation Safety Program, "ORM applied beforehand will prevent a

mishap. Applied afterward, it will prevent its recurrence.,,37

There are five steps to the ORM decision-making process: (1) Identify Hazards, (2)

Assess Hazards, (3) Make Risk Decisions, (4) bnplement Controls, and (5) Supervise.38 CWs

are designed to assist leadership with identifying the hazards that affect organizational

perfonnance (Step (1». Once the hazards are identified, it is the responsibility of the

commanding officer to execute the four remaining steps to achieve excellence.

16

CHAPTER 4

ORIGINS OF THE CULTURE WORKSHOP (CW) PROGRAM

In 1992, Colonel Alan Groben, a Maintenance Officer in the Air National Guard,

developed a unique theory that challenged the traditional philosophy on the conduct of

investigating aviation mishaps.39 Col Groben explained that, "many recent mishaps occurred

not because an individual forgot to perform a required inspection or a pilot violated a regulation

or procedure. Instead, he argued, there were dysfunctional unit cultures that allowed the errors to

happen, and these cultures were the root causes of the mishaps."4o The paradigm shift from

identifying causal factors and instituting measures to prevent future occurrence, to a theory of

identifying the culture as the reason for a mishap, was tested in the Air National Guard units.

The program was groundbreaking because it focused on the culture of an organization rather than

a specific individual who committed the error causing a mishap. Thus Col Groben's "Cultural

Assessment Program" was bom.41

CW Requirements

Four years after the Cultural Assessment Program was instituted in the Air National

Guard, the Navy became interested in implementing Col Groben's program for naval aviation.

After obtaining a directive from the Secretary of Defense to reduce mishaps 50% by FY 2000,

the Navy held a Human Factors Quality Management Board.42 The Navy adopted Col Graben's

Cultural Assessment Program and changed the program's name to "The Culture Workshop (CW)

Program." The Marine Corps joined the Navy's effort in instituting a CW program and

established the Warrior Preservation Camp.aign 2006 to assist Marine commanders in reducing

mishaps.43 The Navy required all deployable aviation squadrons to complete a workshop during

their inter-deployment training cycle and for non-deployable units to complete a workshop once

17

during each two-year period.44 In contrast, the Marine Corps made the CW an optional

requirement for aviation units to conduct a workshop every two years.45

Purpose

The CW Program is an important assessment tool for the unit.commander. A unit's

organizational culture influences the development ofpractices, shared values, or habits that can

either create a successful unit or ultimately contribute to a mishap. CW's assist the unit

commander by identifying organizational strengths and potential hazards that are often the result

of a unit's culture. During the workshop, a trained facilitator conducts multiple seminars to

detennine shared assumptions between seminar participants to examine cultural perceptions and

trends. After the CW seminars, the facilitator compiles the data derived from the seminar

discussions and conducts a confidential debrief to the unit commander. The confidentiality

between the facilitator and unit commander is an important process to the CWo The CW is not

an inspection program. The CW is a non-attribution process and is specifically designed for the

unit commander to "self assess" his organization's performance. The commander can use the

confidential information to identify hazards, mitigate risks, and instill a culture change if it is

required. Aviation units have utilized this viable assessment tool since 1996. To put the CW

effectiveness into perspective, during FY 2004 and FY 2005- of the 168 squadrons (64% ofthe

total Navy/Marine Corps squadrons) that conducted a CW, only 7 squadrons had a Class "A"

mishap after a workshop. Squadrons that failed to conduct a CW accounted for 85% of all Class

"A" mishaps.46

18

Mission Statement

The mission statement for the CW Program is, "Operational excellence exists on a

foundation oftrust, integrity, and leadership, created and sustained through effective

communication. ,,47 The purpose of the mission statement is to provide the worksh~p participants

with a clear understanding that seminars are centered on the discussion of communication, trust,

and integrity. Leadership is not directly discussed in the seminars, per se. The CW Facilitator

points out that leadership roles and responsibilities within the participating organization are

never challenged. The overall intent of the workshop is to identify perceptions and trends for the

unit's leader to identify issues and to affect a culture change. Ultimately, the leader is

responsible for the performance ofhis unit.

Tlu'ee Pillars of the CW

Communication, trust; and integrity are essential elements for a unit to succeed. During a

CW, the pillars of Communication, Trust, and Integrity are discussed among the group in an

open fOlUm. Discussing the pillars in an open fOlUm stimulates the group to "open up" on what

they know and perceive about their respective organization. The seminars are non-attribution.

Eliciting perceptions from the group, the facilitator identifies cultural trends, good or bad, that

might affect the perfonnance of the organization. Discussions of the three pillars provide the

facilitator critical information that the unit commander may not be aware of. On the topic of

assessing cultural dimensions, Schein concluded that, "Culture can be assessed by means of

various individual and group interview processes, with group interviews being by far the best

method in terms of both validity and efficiency... ,,48

19

1. Communication

Communication affects organizational performance at all stratums within a unit and is the

backbone for any leader from the fire team leader/shop supervisor to the battalion/squadron

commanding officer.49 Communication is what binds a unit together- without it nothing will be

done. In order for communication to be effective, infOlmation must be clearly sent and received

by the sender and receiver respectively. In addition to the two-way flow of communication, both

sender and receiver must confinn the infonnation is correct. CommlUlication is one of the most

critical discussion topics during a CW seminar. Without an effective way to communicate

between subordinates and leaders, mission tasks will not be completed or they will be executed

improperly. Ineffective communication creates the environment for problems to occur. The

Naval Aviation Safety Program states that, " ...uncluttered communications channels runAing up

and down the chain of command will foster a genuine sense of ownership of the safety process

by all hands and produce, thereby, an effective command safety culture. ,,50

2. Trust

"Trust" is defined as, "confidence in the ability, character, or truthfulness of a person or

thing. ,,51 Furthennore, tmst is reliance among members of an organization that provide the

element of teamwork to exist. Without trust, an organization would lack cohesiveness. During a

seminar discussion, participants are asked if they trust an individual based on knowledge and

experience or if they trust someone based on rank and position. The initial tendency by

participants is to not speak during a seminar for fear of retribution. However, participants are

asked by the facilitator not to judge someone based onlikeability; likeability should not hinder

job perfOlmance. For example, a person may not be well liked-but trusted to do the job. Trust is

20

an important subject to discuss because job competence and group reliance. are essential in

carrying out leadership goals.

3. Integrity

"Integrity" is defined as "a rigid adherence to a code or standard ofva1ues."s2 In other

words, integrity is about "doing the right thing when no one's watching." Integrity also means

acting in a professional manner that is commensurate with the military's ethos of "honor,

courage, and commitment." During the seminar, the facilitator asks participants if there are

integrity violations occurring within the unit or outside of nonnal working hours. This particular

subject is sensitive because lack of integrity can lead to punishment of an individual or group and

violations may result in a mishap. Identifying integrity with respect to unit programs and

processes is essential to identify any trend that may hinder organizational performance.

Culture Workshop Trends Analysis

As discussed in chapter 2, the culture of an organization can affect its performance. To

analyze the affects of culture within naval aviation, the Navy instituted a culture workshop

program to identify dysfunctional cultural trends within a unit that may lead to mishaps. Before

discussing the cultural trends in relation to a mishap event, one must reinforce the assumption

that culture is enduring, stable, and entrenched within an organization. Additionally, leadership

creates and maintains the appropriate cultural environment to complete the unit's mission.

Figure 2 provides a graphic data depiction ofthe 288 aviation units that were examined.

55% of the units that conducted a workshop did not have a Class "A" FM during the period

examined.

21

/

-j

I

Naval Aviation 1 Oct 00 to 28 Nov 07

.8% NoCWs &ExperiencedClass A FMs

I!l 7% No CWs &No Class A

FMsI!I 30%

ConductedCWs&

ExperiencllilClass A FM::-s--~

55%ConductedCWs& had

zeroClass A FMs

Figure 2.

Table 1

Of 45 units:No CW, No Class A FMs 24 53%Of 45 units:No CW, Class A FMs 21 47%Of 243 units:Had CW, No Class A FMs 158 ( 65%Of 243 units:Had CW, Had Class A FMs 85 35%

Total 288

Looking closely at the units that conducted a workshop and still had a mishap (30%)

during the seven-year period, 65% of the 243 aviation units that conducted a workshop did not

experience a Class "A" FM (Table 1). In contrast, only 35% of the 243 units still experienced a

mishap (Table 1). There are two primary reasons why 85 squadrons out of the 288 squadrons

accounted for, still experienced mishaps. First, the data does not account for the periodicity of

whether a mishap occuned before or after a workshop. The research merely correlated the data

over the seven-year period. In fact, the percentage of units that conducted a workshop and

experienced a mishap dropped when calculated during FY 2006 and FY 2007 (Figure 3).

Historically, the NSC presents CW data by analyzing two-year periods. Second, mishaps could

22

be attributable to material failures that are not the result of human error. In summary, Figure 2

and Table 1 suggest that culture workshops are effective in preventing Class "A" FMs.

A second analysis of the correlation of workshops to mishaps was conducted for FY 2006

through FY 2007. The results shown in Figure 3 depict more impressively the effectiveness of a

CWo Of the 181 squadrons that conducted a CW, only 13 squadrons had Class "A" FMs after a

CWo In comparison, 23 squadrons that failed to conduct a CW before a mishap occurred- each

experienced a mishap. Therefore, 64% of the mishaps from FY 2006- FY 2007 were either from

squadrons that did not conduct a CW or squadrons that experienced a Class "A" FM before

conducting a CWo Figure 3 illustrates how the CW process attributes to improving a squadron's

organizational effectiveness and operational excellence.

Which Column Would You Rather Be In?

r

200

180

180

140

120

100

80

60

40

20

oSquadrons w/out a Culture Workshop Squadrons With Culture Workshop(CW) or had Class A FM before a CW

tlSquadrons _ClassA Flight Mishaps (FMs)

Figure 3.

Tables 2 tlu'ough 7 (Appendix A) provide detailed infoffilation of Navy and Marine

Corps squadrons and further compares rotary-wing to fixed wing units. After reviewing the

aforementioned tables, it is clear that Navy units reap the benefits of conducting a workshop as

compared to Marine aviation units (See Tables 6 and 7, Appendix A). This may be due to the

23

Ij

-I

J

Navy requirement of conducting a CW during inter-deployment training cycles and a CW every

two years for non-deployable units. In contrast, Marine units optionally conduct a workshop

every two years- regardless if the units deploy or not. The data also suggests that the frequency

of conducting a workshop reduces the likelihood ofhaving a Class "A" FM in the future.

There are three reasons why the analytical data for Marine units are not as favorable as

the Navy's. First, Marine units have a different "sub-culture." Their mission sets are very much

different from the Navy's. In other words, Marines fly riskier missions in demanding

environments. This is not to imply that Navy units have easier missions.

GWOT Mishaps v. Class A FM's

90

80

70

60

50

40

30

20

10

oUSN USMC

Figure 4.

",',.'.

Figure 4 breaks down the number ofmishaps that occurred in support of the Global War on

Tenor (GWOT). Specifically, GWOT refers to flying in Afghanistan, Iraq, and the Hom of

Africa. Of the 70 Marine Class "A" FMs during the seven-year period, 18 (26%) of the mishaps

occurred in support of GWOT. In comparison, of the 87 Navy Class "A" FMs, only 6 (7%) were

lost in support of GWOT. Marines had more exposure to combat and the desert environment as

oppose to the Navy during this time period. Second, Marine leadership does not enforce units to

have a CW every two years. Workshops are optional and considered as a voluntary tool for

24

Marine commanders. Third, there are not enough Navy and Marine Facilitators to fulfill a

squadron's request for a culture workshop. The demands of requesting a CW exceed the supply

ofFacilitators.

Culture Workshop Expansion

Expansion of the CW Program beyond naval aviation units is a strong testament to the

viability of the program in preventing or reducing mishaps and increasing operational excellence.

Since the Columbia mishap in 2003, NASA invited naval CW facilitators to conduct workshops

to identify potential hazards within their organization. Large departmental organizations such as

the USS Harry S. Truman and the USS Ronald Reagan also participated in the workshop

process. With assistance from the NSC, naval submarine units established their own workshop

program adjusted to meet their requirements. Finally, U.S. Coast Guard stations have taken

advantage of the CW process to identify trends that affect their organization.

Also noteworthy ofmentioning is an initiative to identify organizational trends in Marine

Corps ground combat elements. Headquarters U.S. Marine Corps Safety Division, with help

from the NSC and 4th Marine Aircraft Wing Workshop Facilitators, conducted beta testing of the

workshop process with great success.S3 Known as the Commander's Warrior Workshop

Program, unit c?mmanding officers that participated in the workshop supported the process and

, actively promoted the workshop program to other commanding officers. The CW expansion is

attributed to its non-attribution of information. One commander stated that, "the workshop is a

superb opportunity to get an objective view of the battalion's culture."S4 Moreover, another

commander was quoted in a critique saying there was "great feedback fi.-om all levels within the

battalion-some positive, some negative, but all worthwhile."ss

25

CHAPTERS

CONCLUSION

0rganizational culture impacts a unit's perfonnance. Climate, leadership, and the

members of an organization are intertwined and they contribute to the creation, maintenance, and

change to organizational culture. The human element in organizational culture is dynamic and

affects the nonnalcy and stability of the organization. Understanding the hlilllan element will

help leadership identify cultural success or failure.

The NASA and US Airways case studies provided examples on how dysfunctional

cultures can lead to catastrophic events. Unfortunately, the loss oflife and negative press

experienced by NASA and US Airways forced leadership to change culture. They also

demonstrated that identifying negative trends by pro-active leaders can change culture to ensure

future success.

Naval aviation is inherently dangerous. For this reason, aviation safety programs are

implemented by commanding officers to eliminate or control potential causes of damage and

injury to aircraft and personnel. Programs such as the Culture Workshop provide unit

commanders a tool to identify hazards that contribute to aviation mishaps.

Culture workshops are effective in reducing or preventing mishaps. The data examined

show units that conducted workshops have fewer or no mishaps than those units which did not

complete a workshop. A leader who understands the human dynamics within his organization

will ensure cultural success and operational excellence.

26

Recommendations

Marine commanders should follow a similar rule like the Navy by instituting a

mandatory requirement for squadrons to conduct a culture workshop during their six-month

deployment cycle or when there is a squadron change of command. Increasing the periodicity

for a workshop will reduce or prevent Class "A" FMs and will identify hazards that impact

organizational performance. Pro-active leadership plays apivotal role in identifying

dysfunctional cultural trends. During an interview with RADML Turcotte, he stated that, "a

commanding officer's attitude and actions will ultimately decide the direction that a squadron

takes."s6 ill addition, the Department ofthe Navy should support the NSC's effort in

establishing a Culture Workshop division that is fully funded and fully staffed to fulfill the

demanding requests for a workshop by the squadrons.

27

-I

Notes

I Adrienne Colella, Michael A. Hitt, and C. Chet Miller, eds., Organizational Behavior: A StrategicApproach (New York, NY: Wiler, 2005), 498.

2 Nanci Hannon, "A Study ofthe Effect ofOrganizational Culture on Leadership Practices within DefenseAgencies JJ (USAWC Strategy Research Project, AY 2000), 2.

3 Naval Safety Center, "Human Factors Council Presentation," January 1,2005,2,http://www.safetycenter.navy.mil/presentations/aviation/hfaccouncil.htm. (accessed February 1, 2008).

4 Department of the Navy, Naval Aviation Safety Program, OPNAV Instruction 3750.6R (Washington,DC: Office of the Chief ofNaval Operations, March 1,2001), 1-1.

5 Robert Figlock, "CSA/MCAS (Command Safety Assessment/Maintenance Climate)", Advanced SurveyDesign (January 26, 2008), http://www.advancedsurveydesign.com/index_files/Page724.htm (accessedJanuary 26, 2008).

6 Edgar H. Schein, Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 2004), 17.

7 Paul Hersey, Kenneth Blanchard, and Dewey Johnson, eds., Management ofOrganizational Beh1;~ior(New Jersey: Prentice-Hall, Inc., 1996), 173.

8 Schein, 12.

9 Schein, 13.

10 Schein, 27.

II Col Mark Schulte and Maj Robert Rubio, "Leadership and Culture, JJ Marine Corps Gazette 91, no.5(May 2007): 26.

12 Col Schulte and Maj Rubio, 26.

13 Hannon, 3.

14 Schein, 409.

15 Schein, 11.

16 Schein, 11.

17 Colella, Hitt, and Miller, eds., 498.

18 Janice M. Beyer and others, Ties That Bind, Neil M. Ashkanasy, Celeste P.M. Wilderom, and Mark F.Peterson, eds., Handbook ofOrganizational Culture and Climate (Thousand Oaks, CA: SagePublications, Inc., 2000), 336.

28

Notes (Cont'd)

19 Barbara Kellerman, "What EvelY Leader Needs to Know About Followers, JJ Harvard Business Review,December 2007,87-91.

20 Robert E. Mittelstaedt, Jr., Will Your Next Mistake BE FATAL? Avoiding the Chain ofMistakes ThatCan Destroy Your Organization (Upper Saddle River, NJ: Wharton School Publishing, 2005), 122-131.

21 Mittelstaedt, Jr., 196-197.

22 Mittelstaedt, Jr., 123.

23 Mittelstaedt, Jr., 123.

24 Mittlestaedt, Jr., 123.

2S Mittlestaedt, Jr., 124.


27 RADML Steve Turcotte, "The Columbia Mishap. An interview with RDML Steve Turcotte, "by CAPTGeorge Platz, LtCol Rick Boyer, and Derek Nelson, Approach (March~April2004): 7.

28 RADML Turcotte, 8.


30 Joseph 1. Soeters, Culture in Uniformed Organizations, Ashkanasy, Wilderom, and Peterson, eds., 465.

31 Ashkanasy, Wilderom, and Peterson, eds., 471.

32 Department of the Navy, Department ofthe Navy O~jectives for FY 2008 and Beyond, Memorandum(Washington, DC: Secretary ofthe Navy, October 9, 2007), 3.

33 Department ofthe Navy, Naval Aviation Safety Program, OPNAV Instruction J750.6R (Washington,DC: Office of the Chief of Naval Operations, March 1,2001),1-1.

34 Department of the Navy, Naval Aviation Safety Program, 1-2.

3S Robert Figlock, "CSA/MCAS (Command Safety AssessmentlMaintenance Climate)", Advanced SurveyDesign (January 26, 2008), hUp://www.advancedsurveydesign.comlindexjiles/Page724.htm (accessedJanuary 26, 2008).

36 Capt. Ken Neubauer, "Managing Risk to Operate: Making ORM Part of Navy Culture", ORM: TheEssentials, (Summer 2007), 2. http://www.safetycenter.navy.mil/media/ORM_speciaUssue/default.htm(accessed February 1,2008).

v,

29

..

Notes (Cont'd)


38 Department of the Navy, Naval Aviation Safety Program, 1-4-1-5.

39 Lt Pat DeConcini, "Culture Shock, JJ The Combat Edge, (January 1995): 28.

40 Lt DeConcini, 28.


42 Naval Safety Center, Culture Workshop Facilitator Selection and Training Program,COMNAVSAFECENINST 1500.2, (NAS Norfolk, VA: Naval Safety Center, August 1, 2005) 1.

43 Headquarters U.S. Marine Corps, Warrior Preservation Campaign 2006. Marine Take Care ofTheirOwn, Pamphlet (Washington, DC: Headquarters U.S. Marine Corps Safety Division, 2006), 16.

44 Naval Safety Center, Culture Workshop, PowerPoint Brief, accessed January 22, 2008, 6,http://www.safetycenter.navy.mil/culture/default.htm (accessed January 22,2008).

\~; ,

45 Headquarters U.S. Marine Corps, Operational Risk Management (ORM) and Fundamentals Ca/npaign,Routine Message Traffic, (Washington, DC: Headquarters U.S. Marine Corps Safety Division, DTG121432Z May 2004), 1.


47 Naval Safety Center, Culture Workshop Facilitator Selection and Training Program, 1.

48 Schein, 361.





53 Col Schulte and Maj Rubio, 26-29.



56 RADML Turcotte, 8.

30

Glossary

Mishap classification was derived from the Naval Aviation Safety Program (OPNAV 3750.6R).

Naval Aviation Mishap Categories:

a. Flight Mishaps (FM)- This category encompass those mishaps which result in $20,000 ormore damage to a DOD aircraft or UAV or, the loss ofDOD aircraft or UAV-when intent forflight for DOD aircraft or UAV existed at the time of the mishap. Other property damage, injuryor death is inelevant to this classification.

b. Flight-Related Mishaps (FRM)- Those mishaps which result in less than $20,000 damage toa DOD aircraft or UAV- when intent for flight existed at the time ofthe mishap and,additionally, $20,000 or more total DOD and non-DOD damage or a reportable injury or deathoccurred.

c. Aviation Ground Mishap (AGM)- Those mishaps in which the intent for flight did not existbut a DOD aircraft or UAV was lost, or more than $20,000 damage was sustained by a DODaircraft or VAV, or DOD or non-DOD property was damaged in the amount of $20,000 or more,or a reportable injury occurred.

Naval Aviation Mishap Severity Classes:

a. Class "A" Severity- A Class "A" mishap is one in which the total cost of damage to propertyor aircraft or UAVs exceeds $1,000,000, or a naval aircraft is destroyed or missing, or anyfatality or permanent total disability results from the direct involvement of naval aircraft orUAV. Loss of a UAV is not a Class "A" unless the cost is $1,000,000 or greater.

b. Class "B" Severity- A Class "B" mishap is one in which the total cost of damage to propertyor aircraft or UAVs is more than $200,000 but less than $1,000,000, or a permanent partialdisability or the hospitalization of three or more personnel results.

c. Class "C" Severity- A Class "c" mishap is one in which the total cost or damage to propertyor aircraft or UAVs is $20,000 or more, but less than $200,000, or an injury requiring five ormore lost workdays results.

Note: Any occurrence in which the total cost ofproperty or aircraft or UAV damage is less than$20,000 and there are no repOliable injuries is not an aviation mishap. Report these events ashazards. Refer to Chapter four of the Naval Aviation Safety Program (OPNAV 3750.6R).

31

j Bibliography

Ashkanasy, Neal M., Celeste P.M. Wilderom, and Mark F. Peterson, eds. Handbook ofOrganizational Culture and Climate. Thousand Oaks: Sage Publications, Inc, 2001.

Colella, Adrienne, Michael A. Hitt, and C. Chet Miller, eds. Organizational Behavior: AStrategic Approach. New York, NY: Wiley, 2005.

DeConcini, Lt. Pat. "Culture Shock." The Combat Edge, January 1995,28-31.

Department of the Navy. Naval Aviation Safety Program. OPNAVINST 3750.6R. Washington,DC: Office ofthe Chief ofNaval Operations, March 1,2001.

Department ofthe Navy. Department ofthe Navy Objectives for FY 2008 and Beyond.Memorandum for Distribution. Washington, DC: Secretary ofthe Navy, October 9,2007.

Figlock, Robert. "CSAJMCAS (Command Safety Assessment/Maintenance Climate)",advancedsurveydesign.com, January 26, 2008.http://www.advancedsurveydesign.com/index.htm (accessed January 26,2008). ,f,

HalIDon, Nanci. "A Study ofthe Effect of Organizational Culture on Leadership Practices withinDefense Agencies." Strategy Research Project. U.S. Army War College,2000.

Headquarters U.S. Marine Corps. Warrior Preservation Campaign 2006: Marines Take Care OfTheir Own. Pamphlet. Washington, DC: Headquarters U.S. Marine Corps SafetyDivision, 2006.

Headquarters U.S. Marine Corps. Marine C07PS Safety Program. MCO 5100.29A Ch. 1.Washington, DC: Headquarters U.S. Marine Corps Safety Division, July 1, 2004.

Hersey, Paul., Blanchard, Kenneth., and Johnson, Dewey, eds. Management ofOrganizationalBehavior. New Jersey: Prentice-Hall, Inc., 1996.

Kellennan, Barbara. "What Every Leader Needs to Know About Followers." Harvard BusinessReview, December 2007.

Matthews, William. "A Zero-tolerance Attitude May Be Showing Results." Air Force Times,May 20,1996.

Mittelstaedt, Jr., Robert E. Will Your Next Mistake BE FATAL? Upper Saddle River, NJ:Wharton School Publishing, 2005.

Naval Safety Center-Code 10. "Lessons Leamed From Aviation Culture Workshops." Mech: TheNaval Safety Center's Aviation Maintenance Magazine, (Winter 2004-05): 9.

32

Bibliography (Cont'd)

Naval Safety Center. "Culture Workshop. "PowerPoint Brief.http://www.safetycenter.navy.mil/culture/default.htm (accessed January 22,2008).

Naval Safety Center. Culture Workshop Facilitator Selection and Training Program.COMNAVSAFECENINST 1500.2. NAS Norfolk, VA: Naval Safety Center, August 1,2005.

Naval Safety Center. "Human Factors Council Presentation. " PowerPoint Brief. NAS Norfolk,VA: Naval Safety Center, 2005.http://www.safetycenter.navy.mil/presentations/aviation/hfaccounci1.htm (accessedFebruary 1, 2008).

Neubauer, Capt. Ken, "Managing Risk To Operate: Making ORM Part of Navy Culture", ORM:The Essentials, Summer 2007.http://www.safetycenter.navy.mil/media/ORM_special_issue/default.htm (accessedFebruary 1, 2008).

Platz, Capt. George, Boyer, LtCol Rick, and Nelson, Derek. "The Columbia Mishap. Aninterview with RDML Steve Turcotte." Approach, March-April 2004, 6-9.

Quessenberry, Capt. Dave, and Boyer, LtCol Rick. "Culture Workshops." Approach, MarchApril 2004, 2-3.

Rubio, Maj Robert. "Commander's Warrior Workshops." Marine Corps Center for LessonsLearned. www.mcc11.usmc.mil (accessed February 23,2007).

Headquarters U.S. Marine Corps. Operational Risk Management (ORM) and FundamentalsCampaign. Routine Message Traffic. Washington, DC: Headquarters U.S. MarineCorps, DTG 121432Z May 04.

Schein, Edgar H. Organizational Culture and Leadership (Jossey-Bass Business &Malwgement). San Francisco: Jossey-Bass, 2004.

Schulte, Col Mark, and Rubio, Maj Robert. "Leadership, Culture, and Operational Excellence: ASymbiotic Relationship." Marine Corps Gazette 91, no.5, May 2007,26-29.

33

J,

APPENDIX A

NAVY AND MARINE CW TABLES

Table 3

~~

Table 6

Of 13 units:No CW, No Class A FMsOf 13 units:No CW, Class A FMsOf 29 units:Had CW, No Class A FMsOf 29 unlts:Had CW, Had Class A FMs

Total

Table 5

Of 18 units:No CW, No Class A FMsOf 18 units:No CW, Class A FMsOf 23 units:Had CW, No Class A FMsOf 23 units:Had CW, Had Class A FMs

Total

Table 7

6

7181142

10111241

46%54%62%38%

44%56%48%52%

~5~i:~!'f~~y,11~1&gQz~[tlrt¥~~i!fg!!1IJ51!§1\\tljfl{tt$MU5X~~r1fi~rl!1W£ti;l;lOf 14 unlts:No CW, No Class A FMs 10 71 %Of 14 units:No CW, Class A FMs 4 29%Of 191 units:Had CW, No Class A FMs 129 68%Of 191 units:Had CW, Had Class A FMs 62 32%

Total 205

34

~&g~~m,$:ry'!:%~§llS~!lZi'g,t~!wjY:llUfg]!!lD~iJ~j;~~~~~1lc!J,!1jJ§.t1~91i'1Of31 units:No CW, No Class A FMs 14 42%Of 31 units:No CW, Class A FMs 17 58%Of 52 units:Had CW, No Class A FMs 29 56%Of 52 unlts:Had CW, Had Class A FMs 23 44%

Total 83

--i(],-:~uij!!!j£.--=ilrp-=----------- · 2011-05-14 · in addition, two case studies (nasa and...

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